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Corneal Pachymetry Using Ultrasound
MA07.046g

Policy

MEDICALLY NECESSARY

Corneal pachymetry using ultrasound is considered medically necessary and, therefore, covered when it is performed as part of medical management for any of the following:
  • Assessing disease progression in corneas with endothelial cell dysfunction (e.g., Fuchs' endothelial dystrophy, posterior polymorphous dystrophy, endotheliitis, corneal trauma)
  • Assessing corneal edema
  • Assessing the health of corneal transplants
  • Aiding in the early diagnosis and/or treatment of corneal transplant rejection
  • Assessing the response of corneal transplant rejection to treatment
  • Assisting in the selection of the appropriate cataract surgical technique for individuals with prior intraocular surgery or established corneal diseases
  • Assessing the risk of corneal decompensation before and after cataract surgery in corneas with known endothelial disease
  • Assisting in the diagnosis of corneal thinning disorders (e.g., keratoconus, keratoglobus, keratotorus, posterior keratoconus, pellucid marginal degeneration)
  • Assessing corneal ectasia (e.g., keratoconus, pellucid marginal degeneration) or progressive corneal ectasia following keratorefractive surgery
  • Determining the influence of corneal thickness on intraocular pressure (IOP) measurements in individuals with suspected or established glaucoma
    • Performed once per lifetime
NOT MEDICALLY NECESSARY

Corneal pachymetry using ultrasound is considered not medically necessary and, therefore, not covered when it is performed for any of the following:
  • As part of an evaluation for refractive surgery
  • To evaluate refractive errors
  • As part of a screening process only (e.g., no evidence exists to suspect a diagnosis of glaucoma)
  • As a routine preoperative evaluation for cataract surgery, unless there is known endothelial disease
  • As a routine postoperative evaluation for any procedure other than a corneal transplant
  • Repeat testing on individuals with suspected or established glaucoma
  • For all other diagnoses or conditions that do not meet the medical necessity criteria listed above
REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

Corneal pachymetry using ultrasound should only be used if it will impact decisions regarding the medical management of the individual.

There is no Medicare coverage determination addressing this service; therefore, the Company policy is applicable.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, corneal pachymetry using ultrasound is covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in the medical policy are met.

However, services that are identified in this policy as not medically necessary are not eligible for coverage or reimbursement by the Company.

BILLING GUIDELINES

Corneal pachymetry using ultrasound should be reported only once when using CPT code 76514. Corneal pachymetry is considered a bilateral procedure. Modifier 50 should not be used when reporting corneal pachymetry using ultrasound.

Corneal pachymetry using ultrasound has both professional and technical components. When claiming only one of these components, append the appropriate modifier for the service performed (Modifier 26 or Modifier TC).

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

Description

Corneal pachymetry using ultrasound is a specialized, noninvasive, ophthalmologic procedure that uses a pachymeter to measure corneal thickness. Measurements of central corneal thickness are performed by applying a topical anesthetic to the eye and placing an ultrasound probe on the central cornea where ultrasonic wave energy is passed into the eye.

Corneal pachymetry using ultrasound is primarily used to assist with the diagnosis, assessment, and/or monitoring of corneal diseases and to assess suspected or established glaucoma. For example, corneal pachymetry using ultrasound is used to assist with the diagnosis of corneal thinning disorders (e.g., keratoconus, keratoglobus, keratotorus, posterior keratoconus, pellucid marginal degeneration). Corneal pachymetry using ultrasound is also included in the assessment and/or monitoring of disease progression of many conditions or injury affecting the cornea such as Fuchs' endothelial dystrophy, posterior polymorphous dystrophy, corneal edema, endothelial disease from any etiology, bullous keratopathy, corneal ectasia, and corneal trauma.

Corneal pachymetry using ultrasound is an important component of the assessment and management of intraocular pressure and glaucoma. Corneal thickness is important because it can mask an accurate reading of intraocular pressure in glaucoma. Actual intraocular pressure may be underestimated in individuals with thinner central corneal thickness or overestimated in individuals with thicker central corneal thickness. Because intraocular pressure is reportedly the most important and only variable risk factor for glaucoma progression, knowledge of the central corneal thickness is important in managing individuals with either suspected or established glaucoma. Repeat measurements of central corneal thickness for suspect or established glaucoma is not indicated unless the individual has corneal disease or has had surgery affecting corneal thickness. Corneal pachymetry for suspected or established glaucoma only needs to be performed once to obtain baseline glaucoma risk information.

In addition to assisting with the diagnosis, assessment, and/or the monitoring of corneal diseases and assessing suspected or established glaucoma, corneal pachymetry using ultrasound is valuable in the selection of appropriate surgical techniques and assessment of the individual's risk and response to certain ophthalmologic surgical procedures (e.g., corneal transplant surgery, cataract surgery). Corneal pachymetry using ultrasound is effective in aiding the early diagnosis and/or treatment of corneal transplant rejection, as well as assessing the response to treatment of corneal graft rejection. The procedure may be used to assess corneal graft health. Corneal pachymetry using ultrasound is also considered for assessing the risk of corneal decompensation before and after cataract surgery for individuals with endothelial disease.

References

American Academy of Ophthalmology. Glaucoma Panel. Preferred Practice Pattern® Guidelines. Primary Open-Angle Glaucoma Suspect. San Francisco, CA: American Academy of Opthalmology; 2015. Available at: http://www.aaojournal.org/article/S0161-6420(15)01278-6/pdf. Accessed August 08, 2023.

American Academy of Ophthalmology. Refractive Management/Intervention Panel. Preferred Practice Pattern® Guidelines. Refractive errors and refractive surgery. San Francisco, CA: American Academy of Opthalmology; 2017. Available at: https://www.aao.org/preferred-practice-pattern/refractive-errors-refractive-surgery-ppp-2017. Accessed August 08, 2023​.

Brandt JD, Beiser JA, Kass MA, et al. Central corneal thickness in the ocular hypertension treatment study (OHTS). Ophthalmology. 2001;108(10):1779-1788.

Cheng AC, Rao SK, Lau S, et al. Central corneal thickness measurements by ultrasound, Orbscan II, and Visante OCT after LASIK for myopia. J Refract Surg. 2008;24(4):361-365.

Dueker D, Singh K, Lin S, et al. Corneal thickness measurement in the management of primary open-angle glaucoma: A report by the American Academy of Ophthalmology. Opthlamology. 2007;114:1779-1787.


Gedde SJ, Vinod K, Wright MM, et al. Primary Open-Angle Glaucoma Preferred Practice Pattern®. Ophthalmology. 2021;128(1):P71-P150. doi:10.1016/j.ophtha.2020.10.022.

Giraldez Fernandez MJ, Diaz Rey A, Cervino A, Yebra-Pimentel E. A comparison of two pachymetric systems: Slit-scanning and ultrasonic. CLAO J. 2002;28(4):221-223.


Jacobs DS, Afshari NA, Bishop RJ, et al. Refractive Errors Preferred Practice Pattern®. Ophthalmology. 2023;130(3):P1-P60. doi:10.1016/j.ophtha.2022.10.031.


Jacobs DS, Lee JK, Shen TT, et al. Refractive Surgery Preferred Practice Pattern®. Ophthalmology. 2023;130(3):P61-P135. doi:10.1016/j.ophtha.2022.10.032.

Kass MA, Heuer DK, Higginbotham EJ, et al. The ocular hypertension treatment study: a randomized trial determines that topical ocular hypertensive medication delays or prevents the onset of primary open-angle glaucoma. Archiv Ophthalmol. 2002;120(6):701-713.

Li EY, Mohamed S, Leung CK, et al. Agreement among 3 methods to measure corneal thickness: ultrasound pachymetry, orbscan II, and visante anterior segment optical coherence tomography. Ophthalmology. 2007;114(10):1842-1827.

Modis L Jr, Szalai E, Nemeth G, Berta A. Reliability of the corneal thickness measurements with the pentacam HR imaging system and ultrasound pachymetry. Cornea. 2011;30(5):561-566.

Palmberg P. Answers from the ocular hypertension treatment study. Arch Ophthalmol. 2002;120(6):829-830.

Phillips LJ, Cakanac CJ, Eger MW, Lilly ME. Central corneal thickness and measured IOP: A clinical study. Optometry. 2003;74(4):218-225.

Rainer G, Petternel V, Findl O, et al. Comparison of ultrasound pachymetry and partial coherence interferometry in the measurement of central corneal thickness. J Cataract Refract Surg. 2002;28(12):2142-2145.

Rainer G, Petternel V, Findl O, et al. Comparison of ultrasound pachymetry and partial coherence interferometry in the measurement of central corneal thickness. J Cataract Refract Surg. 2002;28(12):2142-2145.

Reinstein DZ, Silverman RH, Raevsky T. Arc-scanning very high-frequency digital ultrasound for 3D pachymetric mapping of the corneal epithelium and stroma in laser in situ keratomileusis. J Refract Surg. 2000;16(4):414-430.

Taravella M, Walker M. Postoperative corneal edema. [Medscape Web site]. Updated 10/16/2018. Available at: http://emedicine.medscape.com/article/1193218-overview. [via subscription only]. Accessed August 08, 2023​.

Wickham L, Edmunds B, Murdoch IE. Central corneal thickness: will one measurement suffice? Ophthalmology. 2005;112(2):225-228.


Yeung KK. Keratoconus. [Medscape Web site]. Updated 10/17/2018. Available at: http://emedicine.medscape.com/article/1194693-overview. [via subscription only]. Accessed August 08, 2023​.​

Coding

CPT Procedure Code Number(s)
76514
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
See Attachment A.
HCPCS Level II Code Number(s)
N/A
Revenue Code Number(s)
N/A


Coding and Billing Requirements

Policy History

Revisions From MA07.046g:
​08/23/2023
​This policy has been reissued in accordance with the Company's annual review process.​
09/19/2022

This version of the policy will become effective 09/19/2022.


The following ICD-10 Diagnosis codes for unspecified eye have been removed from this policy:
H18.10, H18.219, H18.229, H18.239, H18.509, H18.519, H18.529, H18.539, H18.549, H18.559, H18.599, H18.609, H18.619, H18.629, H18.719, H18.799, H21.559, H40.009, H40.019, H40.029, H40.039, H40.049, H40.059, H40.069, H40.1190, H40.1191, H40.1192, H40.1193, H40.1194, H40.1290, H40.1291, H40.1292, H40.1293, H40.1294, H40.1390, H40.1391, H40.1392, H40.1393, H40.1394, H40.1490, H40.1491, H40.1492, H40.1493, H40.1494, H40.219, H40.2290, H40.2291, H40.2292, H40.2293, H40.2294, H40.239, H40.249, H40.30X0, H40.30X1, H40.30X2, H40.30X3, H40.30X4, H40.40X0, H40.40X1, H40.40X2, H40.40X3, H40.40X4, H40.50X0, H40.50X1, H40.50X2, H40.50X3, H40.50X4, H40.60X0, H40.60X1, H40.60X2, H40.60X3, H40.60X4, H40.829, H40.839, H44.519, T86.8409, T86.8419, T86.8489, T86.8499​


Revisions From MA07.046f:
11/17/2021
This policy has been reissued in accordance with the Company's annual review process.
​11/18/2020
​This policy has been reissued in accordance with the Company's annual review process.​
​10/01/2020
​This policy has been identified for the ICD-10 Diagnosis code update, effective 10/01/2020.

The following ICD-10 Diagnosis codes have been removed from this policy:

H18.50, H18.51, H18.52, H18.53, H18.54, H18.55, H18.59, T86.840, T86.841, T86.848, T86.849 
   
The following ICD-10 Diagnosis codes have been added to this policy as Medically Necessary:

H18.501, H18.502, H18.503, H18.509, H18.511, H18.512, H18.513, H18.519, H18.521, H18.522, H18.523, H18.529, H18.531, H18.532, H18.533, H18.539, H18.541, H18.542, H18.543, ​H18.549, H18.551, H18.552, H18.553, ​H18.559, H18.591, H18.592, H18.593, H18.599, T86.8401, T86.8402, T86.8403, T86.8409, T86.8411, T86.8412, T86.8413, T86.8419, T86.8481, T86.8482, T86.8483, T86.8489, T86.8491, T86.8492, T86.8493, T86.8499​

Revisions From MA07.046e:
11/20/2019This policy has been reissued in accordance with the Company's annual review process.
04/02/2018This policy has undergone a routine review, and the following diagnosis codes have been:
  • Removed from Attachment A of this policy:
      H40.142 Capsular glaucoma with pseudoexfoliation of lens, left eye
      H40.143 Capsular glaucoma with pseudoexfoliation of lens, bilateral
  • Added to this policy:
      T85.398D Other mechanical complication of other ocular prosthetic devices, implants and grafts, subsequent encounter
      T85.398S Other mechanical complication of other ocular prosthetic devices, implants and grafts, sequela

Revisions From MA07.046d:
06/21/2017The policy has been reviewed and reissued to communicate the Company’s continuing position on Corneal Pachymetry Using Ultrasound.
​01/02/2017

​This version of the policy will become effective 01/01/2017.

The policy has been reviewed to communicate the Company’s continuing positions on Corneal Pachymetry Using Ultrasound.

The following CPT code has been removed from the policy: 0402T

Effective 01/01/2017: 0402T will be housed and addressed in the Company's medical policy entitled Refractive Keratoplasty (Policy #: MA11.008).

Revisions From MA07.046c:
10/01/2016This version of the policy will become effective 10/01/2016.
This policy has been identified for the ICD-10 CM code update, effective 10/01/2016.

The following ICD-10 CM codes have been deleted from this policy:
    H40.11X0, H40.11X1, H40.11X2, H40.11X3, H40.11X4
The following ICD-10 CM codes have been added to this policy:
    H40.1110: Primary open-angle glaucoma, right eye, stage unspecified
    H40.1111: Primary open-angle glaucoma, right eye, mild stage
    H40.1112: Primary open-angle glaucoma, right eye, moderate stage
    H40.1113: Primary open-angle glaucoma, right eye, severe stage
    H40.1114: Primary open-angle glaucoma, right eye, indeterminate stage
    H40.1120: Primary open-angle glaucoma, left eye, stage unspecified
    H40.1121: Primary open-angle glaucoma, left eye, mild stage
    H40.1122: Primary open-angle glaucoma, left eye, moderate stage
    H40.1123: Primary open-angle glaucoma, left eye, severe stage
    H40.1124: Primary open-angle glaucoma, left eye, indeterminate stage
    H40.1130: Primary open-angle glaucoma, bilateral, stage unspecified
    H40.1131: Primary open-angle glaucoma, bilateral, mild stage
    H40.1132: Primary open-angle glaucoma, bilateral, moderate stage
    H40.1133: Primary open-angle glaucoma, bilateral, severe stage
    H40.1134: Primary open-angle glaucoma, bilateral, indeterminate stage
    H40.1190: Primary open-angle glaucoma, unspecified eye, stage unspecified
    H40.1191: Primary open-angle glaucoma, unspecified eye, mild stage
    H40.1192: Primary open-angle glaucoma, unspecified eye, moderate stage
    H40.1193: Primary open-angle glaucoma, unspecified eye, severe stage
    H40.1194: Primary open-angle glaucoma, unspecified eye, indeterminate stage

Revisions From MA07.046b:
01/01/2016This version of the policy will become effective 01/01/2016. The following CPT code: 0402T has been added to the policy.

Revisions From MA07.046a:
12/30/2015The policy has been reviewed and reissued to communicate the Company’s continuing position on Corneal Pachymetry Using Ultrasound.
10/28/2015This version of the policy will become effective 10/28/2015

ICD-10-CM codes were added and clinically reviewed considering the scope and intent of the policy document and the appropriateness of the codes for the policy.

ICD-10 codes have been added to Attachment A.
10/01/2015This version of the policy will become effective 10/01/2015

ICD-10-CM codes were added and clinically reviewed considering the scope and intent of the policy document and the appropriateness of the codes for the policy.

ICD-10 codes have been added to Attachment A.

Revisions From ​MA07.046:
01/01/2015This is a new policy.

9/19/2022
9/19/2022
8/23/2023
MA07.046
Medical Policy Bulletin
Medicare Advantage
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Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.